Vehicle Accident Information Form
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- Aron McDowell
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1 Vehicle Accident Information Form Patient Name: 1. What was the date of the accident? 2. Approximately what time did the accident occur? : AM / PM 3. How many vehicles were involved in the accident? 4. What was the estimated damage to the vehicle you were in? 5. What street were you on when the accident occurred? 6. What direction were you traveling in? 7. What city did the accident occur in? 8. What state did the accident occur in? 9. What type of impact was the auto accident? 10. Did your vehicle hit anything after the accident (i.e. tree or guard rail)? If yes, please describe 11. Where were you sitting in the vehicle during the accident? 12. Did you know the accident was coming? 13. What type of vehicle were you in? 14. What type of vehicle impacted yours? 15. At the time of the impact you were: -Slowing down -Stopped -Gaining Speed -Moving at a steady speed 16. At the time of the impact, approximately how fast was your vehicle moving? MPH 17. At the time of the impact was the other car was: -Slowing down -Gaining Speed -Stopped -Moving at a steady speed 18. At the time of impact, approximately how fast was the other vehicle moving? MPH 19. During and after the crash what happened to your vehicle? (Please circle all that apply) - kept going straight - spun around - kept going straight hitting a car in front - spun around and hit a stationary object
2 - was hit by another vehicle - hit a stationary object 20. Did you lose consciousness during the accident? Yes / No 21. How was your head positioned during the accident? 22. How was your torso positioned during the accident? 23. How were your hands positioned during the accident? 24. Did your head hit anything during the accident? No / Yes, please describe 25. Did your face hit anything during the accident? No / Yes, please describe 26. Did your shoulders hit anything during the accident? No / Yes, please describe 27. Did your neck hit anything during the accident? No / Yes, please describe 28. Did your chest hit anything during the accident? No / Yes, please describe 29. Did your hips hit anything during the accident? No / Yes, please describe 30. Did your knees hit anything during the accident? No / Yes, please describe 31. Did your feet hit anything during the accident? No / Yes, please describe 32. What kind of headrest was in your vehicle? - movable fixed headrest - non-movable fixed headrest - no headrest 33. Where was the headrest positioned on your head? (Please circle which applies best) - at the top of the back of your head - at the middle height of the back of your head - at the lower portion of the back of your head - at level with the back of your neck - at the level of your shoulder blades 34. Did you have your seatbelt on during the accident? -Yes -No 35. Did you slide out of your seatbelt during the accident? 36. What was damaged in your vehicle? (Please circle all that apply) - windshield - rear window - trunk - steering wheel - mirror - front left door - dashboard - knee bolster - front right door - seat frame - rear bumper - back left door - side window - front bumper - back right door - completely totaled - other: 37. Choose the items that dented inward: - floorboards - side door - dashboard 38. Choose the doors that would not open as a result of the accident: - front left - rear left - front right - rear right
3 39. Did you go to the hospital? If no, why and do not answer How did you get to the hospital? 41. What was the name of the hospital? 42. Were you hospitalized over night? 43. Circle what you were prescribed at the hospital (if applicable): Pain Medication Muscle Relaxers Not Applicable 44. Did you receive any stitches for any cuts at the hospital? If yes, which area(s) of the body? 45. Did you receive any of the following at the hospital? Neck Brace Back Brace Not Applicable 46. Were x-rays taken at the hospital? If yes, which area(s) of the body were they taken? 47. Was an MRI/CT Scan taken at the hospital? If yes, which area(s) of the body were they taken? Patient/Guardian Signature Date:
4 Motor Vehicle Accident (PI/PIP) Billing Information Patient Name Date of Birth Date of Accident 1. Personal Injury Protection Auto Insurance (PIP) Company Name Policy / Claim Number Adjuster Name Adjuster Phone Ext Fax 2. Personal Injury Attorney Information (PI) Attorney Name Attorney Phone Ext Fax Paralegal Contact 3. Major Medical Health Insurance Company Name Company Phone Ext Fax Subscriber ID Group ID
5 ASSIGNMENT OF BENEFITS Patient hereby irrevocably acknowledges full financial responsibility for all services provided to patient by 1rst Health PA (Provider), as consideration for such Provider services. Patient irrevocably assigns to 1rst Health PA (Provider), any and all benefits payable by or from any insurance or health care plan(s) coverage maintained by Patient as consideration for the total fee for those charges incurred by Patient as a result of those services rendered by Provider. Patient also assigns to 1rst Health PA (Provider): (i) any and all benefits payable by or from any automobile medical payment coverage maintained by Patient or any party under whose policy of insurance Patient may have a lawful right of recovery, (ii) any and all benefits payable by or under any third party liability insurance coverage to which Patient may have a right of recovery due to the injuries for which Patient has sought Provider s health care services, and (iii) a common law lien interest in, and all contractual rights and claims to, any and all future insurance proceeds Patient has against any insurance company, health care benefit plan, or any other party contractually liable to Patient for payment of all or any portion of the health care services rendered by 1rst Health PA (Provider), and the resultant charges therefore, to the Patient as a result of the injuries sustained by Patient. This irrevocable Assignment of Benefits, conveyance of lien interest and contractual rights to and for those charges attributable to 1rst Health PA s (Provider) health care services shall extend to, but not be limited to, Provider s entitlement to any and all insurance proceeds remitted as a result of any insurance claim for damages by the Patient which has given rise to the above referenced health care services provider by 1rst Health PA (Provider). By my signature be it know that I have read and fully understand the above contract. Patient Name (Print) Custodian Parent/Legal Guardian (Print) Witness (Print) Date
Motor Vehicle Collision Form
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Automotive Collision Injury Form
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BILLING INFORMATION. Address: City, State, Zip: Telephone Number: Date of Injury: Time of Injury: AM PM City and street where crash occurred:
BILLING INFORMATION Patient Name: Address: City, State, Zip: Telephone Number: Date of Injury: Time of Injury: AM PM City and street where crash occurred: Yes No Do you have automobile medical insurance
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DESCRIBE HOW THE CRASH HAPPENED:
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